CMS Revises Medicare Revalidation Policies
March 16, 2015 02:00 PM
The Centers for Medicare & Medicaid Services (CMS) has issued change Request (CR) 9011 which updates the Medicare Program Integrity Manual on policies related to provider and supplier revalidations.
Sections 15.29.1-15.29.10 of the manual are new and include policies that outline the process and timing for revalidations and subsequent deactivations.
According to the revised policy, CMS will request that providers respond to a revalidation request within 60 days of sending the revalidation letter. If there is no response by day 60, the contractor is to contact the provider between day 60-70. The contractor will make two attempts to contact the provider by telephone. A no answer does not count as a contact, but the contractor may leave a voice message if a phone number is left for a contact directly at the contractor site.
If there is no response to the revalidation request by day 71-75 of sending the revalidation letter, the provider is placed in a “pend” status. The contractor informs the provider of the “pend” status via phone or mail. The method of notification is determined by the contractor. If communication is via phone, two attempts will be made, and if there is no response (voice mail not permitted), a letter will be sent.
While a provider will not receive any payments or remittance reports while in a “pend” status, this action in not applied to the shared systems. Therefore, providers will be able to order or refer services for Medicare beneficiaries. Home health agencies that accept orders from physicians while in this “pend” status will be able to bill Medicare and receive payment for services.
Individual group members who have assigned their benefits to one or more groups are not placed in a “pend” status. Rather, they will be deactivated between day 71-75 for no response to a revalidation request. Physicians who assign their benefits to a group or groups commonly order home health services. Therefore, agencies should be aware that some physicians they work with might have a shorter time interval between a revalidation request and deactivation than other providers.
Providers that are either placed in a “pend” status or deactivated between day 71-75, and do not respond to the revalidation request by day 120-125 from the date the revalidation request was sent, will have their enrollment record deactivated. The provider transaction access number (PTAN) and effective date shall remain the same if the revalidation application was received prior to 120 days after the date of deactivation. If the revalidation is received more than 120 days after deactivation, a new PTAN and effective date will be issued. The time between the end date of the old PTAN and the issuance of a new PTAN will be reflected as a gap in the provider’s enrollment record.
In the CR, CMS states that the contractor shall not require any provider/supplier with billing privileges that have been deactivated to obtain a new State survey or accreditation as a condition of revalidation.
The current regulation §424.540(b)(3)(i) requires a home health agency (HHA) with Medicare billing privileges that have been deactivated to obtain an initial State survey or accreditation by an approved accreditation organization before its Medicare billing privileges can be reactivated, including deactivations related to revalidations.
The National Association for Home Care & Hospice received confirmation from CMS that HHAs would not be required to obtain a State survey or accreditation by an approved accreditation organization if they had been deactivated related to CMS’ revalidation policies. However, in any other case, if the HHA was deactivated CMS would need to follow the regulation requirements.
CMS posted on their web site a list of all providers and suppliers who are currently enrolled in the Medicare (ordering and referring list). The site also contains a list of physician and non-physician providers who have an initial application pending. This pending status list is not the same as the “pend” status related to revalidations. That list is not available to the public. The site also contains a list of providers and suppliers that been sent revalidation letters and a list of providers and suppliers that will be sent revalidation letters within the next 60 days.
The CR also provides information on CMS’ policies related to the process and response timelines for revalidations when additional information has been requested by the contractor. In addition, a new section has been added that addresses punctuation and special characters in the National Provider Identifiers (NPI); and the model letters contractors send to providers to request a revalidation and associated correspondence have been revised.
To view the CR click here.